—_|

case
Annex "C"

Case Report Form Page Number: 1 of 2 1

Dengue (ICD 10 Code: A90-A91) Revision Number: 2020

DOH-EB-PHSD-01 Effectivity:

Province: Municipalityity:
Region
Name of DRU:
_. _ __
Type: FIRHU [JCHO/MMHOPHO [1Gov'tHospital []Private Hospital [Clinic
Address:
Name of interviewer:
COMPLETE CURRENT ADDRESS

ff
COMPLETE PERMANET
(place of residence within 30

| 4a
cit Date admitted!
Patient
vantwio, No,
LaPATENTS FULLNAME
Last name, First name,
name
° | ge
sex
(FM)
ate
pate ol or
Birth days)
HouselBullding #, Street,
Barangay, Municipality/City, '
House/eciding
Street,
tityici
B arangay, Mu Municipality/City,
Status
'4'9¢n©
p eople
Consutt
ed?
Date of First
consultation
Place of
Consultation
Admit
ted? seen:
consulted
116 onset of itiness
(FIRST symptors))
Province Province

ff It.
it. St.
tf wh
ff
tf
atFL
ft —/_/__

Response
rite!
indicate LastName, followed by
“Heatnamaandnicdentme’
Age:

cmon
'
cate
|D-davs_ Sex
}FFemale
ft MMDDIYY
i
Specify House of Building number,
Street, Barangay, Municipalay'Cay,
Provirze, Region
Specify or Builds
pecify H House miber
Building number,
Stron, Barangay, Municipelty Cy
S-Single
M-Married
Sep-
Separated
Widowed
Y-Yes
WN
— f/f
MMDDIYY Name ofFaciity
Y-Yes
|W |
fs PL MMDD/YY UMDDIYY

linigal Cla
tio Case Classification
A. DENGUE WITHOUT SUSPECT
WARNING SIGNS
aeiiness of 2-7_ days duration plus twa of the B. DENGUE WITH WARNING SIGNS C. SEVERE DENGUE A previously well person with acute febrile illness of 2-7 days duration

foun acute febmile

" :

Dengue with at feast one of the following criteria:

with dinical signs and symptoms of dengue
Person with acute febrile illness of 2-7 days duration with any of the
following: oSevere plasma leakage leading to shock and/or fluid accumulation

+ Headache : ® vin
»
+
Abdominal painortendemess
Persistent vornting
©

«
iLaboratory increase>2 on
Liver enlargeme! nt
in HOT
wth respiratory distress
+ Severe bleeding as evaluated by clinidan
OBABLE:
PROBABLE: A Asuspecied
suspeded
case wi with positive dengue [gM
i
antibody test

« Body malaise °
Darhes © Clinical fluid accurnutation Concurrent with rapid decease Severe organ involvement such as AST or ALT >1000, impaired CONFIRMED: A suspected case with positive results for:
° in platelet count
. Myalgia Flu shed skin (ascites, pleural effusion) conscousness and failure of heart and ather organs. Misi
autture
isolation mC

ipo eans
°
. ratgia
Retro-orbital .
rash (petecheal, Herman's . i
i

Polymerase Chain Reaction Per) oF

. Anorexia
pain » Skin
sign)
=
eDengue NS antigen test
« » Restlessness
strict
ob ‘on

and medical :
requires

Deliberately providing false or misleading, personal information on the part of the patient, or the next of kin in case of patient's incapacity, may constitute non-cooperation punishable under the Republic Act. No. 11332

yer
with
Case Report Form Page Number: of 2 1 1

Dengue (ICD 10 Code: A90-A91) Revision Number: 2020

DOH-EB-PHSD-01 Effectivity:

Region: Province: Municipality/City:

Name of DRU: Type: JRHU [ICHO/MHO/PHO []Gov'tHospital (Private Hospital [Clinic

Silnical
Address:
Name of interviewer.
COMPLETE CURRENT AODRESS
(place of residence within 30 con’ LETE
ADDRESS.
aNeT
PATIENTS FULL NAME Indigeno Date admitted/
Sex days) Civil Consult Date of First Place of Admit Date onset ofIliness
ta pate of Birth us
Patient name, First name, Middie A ge
#, House/Bullding #, : Street, ed? “seen
No. No. Firstname,
Status Consultation
Last
Street, consultation -ted?
Middle

(FM) House/Bullding ((FIRST symptom/s))

name Barangay, Municipality/City, People consutted
Barangay, Municipality/City, Province
Province

—_I.
—i_/
tr Jktst
a
a
—/_f
a —fft

It
{sk

so ar
if te
ar
—fft JL
Response

ines
indicate Last Name, followed by
First name, and Middle name
Age:
icate
|D-day3_

yemomns
Sex:
F;Female
tt mMODIYY
Specify House or Building number,
Street, Barangay, Municipality/City,
Province, Region
,

Street, Barangay,
:
Specify House or Building number,
Municipaliyicity,
$-Singte
M-Married
Sep-
Separated
Widowed
Y-Yes
N-No
a a MMIDDIYY Name of Facility
airy Y-Yes
y.No
MMOOIYY MM/DD/YY

Classification Case Classification

A. DENGUE WITHOUT SUSPECT
WARNING SIGNS
ar C. SEVERE DENGUE
flea
B. DENGUE WITH WARNING SIGNS A previously well person with acute febrile iliness of 2-7 days duration
acute febrile iness of 2-7 days duration plus two of the
. ‘

of the
_
Person with acute febrile illness of 2-7 with clinical signs and symptome of dengue
days duration with any Dengue with at least one of the following criteria:
«Severe plasma leakage leading to shock and/or fluid accumulation
*

following:
Abdominal pain ortendemess ° enlargement t>2em
Liver F with respiratory distress A
ent

PROBABLE: suspected case with positive d dengue IgM antibody test

‘ Nausea
positive
ected case IgM antibody

Headache Persistent vemting Laboratory: increase in HCT

>2

>
« * « Severe bleeding as evaluated by
clinician
Body malaise concurrent with rapid decrease
+
« Vomiting
* Clinical fluid accumulation «Severe organ Involvement such as AST or ALT >1000, impaired CONFIRMED: A suspected case with positive results for:
« Myatgia +
Diarhea ( ‘ascites, 1p pleural effusion ) in platetet count consciousness and failure of heart and other organs. Viral cutture Isolation, or
hed skin
or
sk
»Polymerase Chain Reaction (PCR),
. * Flushed
:

« Asthralgia . « Mucosal bleeding

° (petecheal, Herman's Dengue NSt antigen test
. Retro orbital
° x:
pain samen |
e
etnargy
Restlessness
“requires strict observation and medical Intervention
Deliberately providing false or misleading, personal information on the part of the patient, or the next of kin in case of patient's incapacity, may constitute non-cooperation punishable under the Republic Act. No. 11332

yer